Healthcare Provider Details

I. General information

NPI: 1255521928
Provider Name (Legal Business Name): NICOLE SMITH CARLSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD NE SUITE 620
ATLANTA GA
30342-1626
US

IV. Provider business mailing address

980 JOHNSON FERRY RD NE SUITE 620
ATLANTA GA
30342-1626
US

V. Phone/Fax

Practice location:
  • Phone: 404-257-0553
  • Fax: 404-256-4238
Mailing address:
  • Phone: 404-257-0553
  • Fax: 404-256-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN160487
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: